Individual
DR. MALLORY PHILLIPS BODFORD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
O.D.
Contact information
Practice address
6947 CRUMPLER BLVD, OLIVE BRANCH, MS 38654-1922
(662) 893-3300
(662) 893-3301
Mailing address
6947 CRUMPLER BLVD, OLIVE BRANCH, MS 38654-1922
(662) 893-3300
(662) 893-3301
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
8517T
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
05005854
—
MS
01
—
966P-Y
MISSISSIPPI STATE LICENSE
MS
Enumeration date
08/04/2014
Last updated
02/17/2022
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